Maximizing Billing and Coding Part 4:Wrap Up / Coding Scenarios

Presenter: Stacey L. Murphy, MPA, RHIA, CPC18 December 2015

Maximizing Third Party Reimbursement Through Enhanced

Medical Documentation and Coding

Installment Four of the Webinar Series

• 30 years of practice management, physician credentialing/re-credentialing, contract management, and coding and clinicaldocumentation experience.

• Certified Professional Coder (CPC) credentialed by the AmericanAcademy of Professional Coders since 1998 and a Registered HealthInformation Administrator (RHIA) since 2011 credentialed by theAmerican Health Information Management Association (AHIMA). She isalso credentialed by AHIMA as an ICD-10-CM/ICD-10-PCS ApprovedTrainer.

• As the Chief of Health Information Management (HIM) working for theVeterans Administration, she is currently responsible for ensuring that allof the HIMS coding staff are properly trained and ready for the ICD-10coding implementation. She also ensures that documentation andcoding information is disseminated timely to clinicians and otheradministrative staff at the Veterans Administration.

Maximizing Third Party Reimbursement Through Enhanced

Medical Documentation and Coding

Installment 4: Wrap Up – Coding Scenarios

Prepared By: Stacey L. Murphy, MPA, RHIA, CPCAHIMA Approved ICD-10-CM/ICD-10-CM Trainer

The documentation and coding information was produced asan informational reference for the HealthHIV organization. Norepresentation, warranty, or guarantee that compilation of thisinformation is error-free and we bear no responsibility or liabilityfor the results or consequences of the use of this material.Although every reasonable effort has been made to assure theaccuracy of the information contained in the presentation, theinformation is constantly changing and it is the sole responsibilityof the clinician to:

• ensure that best practices in patient care are met.• remain abreast of each health plans regulatory

requirements since regulations, policies and/or codingguidelines cited in this presentation are subject to changewithout further notice.

• ensure that every reasonable effort is made to adhere toapplicable regulatory guidelines within their respectivejurisdiction.

CPT codes, descriptions and material only are

Copyright ©2015 American Medical Association

(AMA). All Rights Reserved. No fee schedules, basic

units, relative values, or related listings are included in

CPT. The AMA assumes no liability for the data

contained herein.

Learning Outcomes• Review CPT, HCPCS and ICD-10-CM codes

learned in series 1, 2 and 3

• Review coding scenarios which reflect accurate reporting of the codes for HIV/AIDS medical care

• Discuss the importance of proper code sequencing

• Discuss the importance of proper documentation and its impact on reimbursement

Acronyms Used• AIDS - Acquired Immunodeficiency Syndrome

• AMA - American Medical Association

• ARC - AIDS Related Complex

• BA – Body Area

• cc - Chief Complaint

• CDC - Centers for Disease Control

• CLIA - Clinical Laboratory Improvement Amendments

• CMS - Centers for Medicare and Medicaid Services

• CPT - Current Procedural Terminology

• Dx – Diagnosis

• EIA - Enzyme Immunoassay

Acronyms Used• ELISA - Enzyme Linked Immunosorbent Assay

• E&M - Evaluation and Management

• EPF - Expanded Problem Focused

• GYN - Gynecology/Gynecologist

• HEDIS - Healthcare Effectiveness Data and Information Set

• HCPCS - Healthcare Common Procedure Coding System

• HHS - Health and Human Services

• HIPAA - Health Insurance Portability and Accountability Act

• HPI - History of Present Illness

• ICD-10-CM - International Classification of Diseases, 10th

Revision, Clinical Modification

Acronyms Used• ICD-10-PCS - International Classification of Diseases, 10th

Revision, Procedure Coding System

• HIV - Human Immunodeficiency Virus

• HIV 1 - Human Immunodeficiency Virus 1

• HIV 2 - Human Immunodeficiency Virus 2

• MDM - Medical Decision Making

• NPI - National Provider Identifier

• OI - Opportunistic Infection

• OS - Organ System

Acronyms Used• PDx - Primary Diagnosis

• SDx - Secondary Diagnosis

• PMFSH - Past Medical, Family and Social History

• PE - Physical Examination

• PF - Problem Focused

• PQRS - Physician Quality Reporting System

• PrEP – Pre-exposure Prophylactics

• QARR - Quality Assurance Reporting Requirements

• ROS - Review of Systems

• WHO - World Health Organization

E&M Service CodesNew Patient Visit

CPT 99201 99202 99203 99204 99205

HISTORY - HPI 1 -3 1-3

>4 acute problems or status of 3

active chronic problems

>4 acute problems or status of 3

active chronic problems

>4 acute problems or status of 3

active chronic problems

HISTORY - ROS N/A 1 2-9 >10 >10

HISTORY - PMFSH 1 1 1 3 3

1995 EXAM (Body areas/organ systems) 1 2-4 5-7

>8 OS or comprehensive exam of 1 single

system

>8 OS or comprehensive exam of 1 single

system

MDM SF SF LOW MOD HIGH

AVERAGE TIME SPENT 10 minutes 20 minutes 30 minutes 45 minutes 60 minutes

E&M Service CodesEstablished Patient Visit

CPT 99211 99212 99213 99214 99215

HISTORY - HPIMay not require the presence of an MD. Typically,5 min are spent performing these services.

1-3 1-3

>4 acute problems or status of 3

active chronic problems

>4 acute problems or status of 3

active chronic problems

HISTORY - ROS N/A 1 2-9 10HISTORY - PMFSH N/A N/A 1 2-3

1995 EXAM (Body areas/organ systems) 1 2-4 5-7

>8 OS or comprehensiv

e exam of 1 single system

MDM SF LOW MOD HIGHAVERAGE TIME SPENT 5 minutes 10 minutes 15 minutes 25 minutes 40 minutes

NOTE: Code 99211 typically reported when minimal services rendered by an RN prior MD orders documented in the medical record

E&M Service CodesPreventive Medicine/Well Visits NEW ESTABLISHED CODE DESCRIPTION

99381 99391 AGE YOUNGER THAN 1 YEAR

99382 99392 EARLY CHILDHOOD (AGE 1 TO 4 YEARS)

99383 99393 LATE CHILDHOOD (AGE 5 TO 11 YEARS)

99384 99394 ADOLESCENT (AGE 12 TO 17 YEARS)

99385 99395 EARLY ADULT (AGE 18 TO 39 YEARS)

99386 99396 ADULT (AGE 40 TO 64 YEARS)

99387 99397 ADULT (AGE 65+ YEARS)

Note: These codes include preventive medicine counseling with risk factor reduction. Do not report CPT codes 99401-99404

E&M Service CodesPreventive Medicine Counseling Visits Preventive Medicine Counseling and/or Risk Factor Intervention Visits (without history and physical exam)

CODE CODE DESCRIPTION99401 15 minutes99402 30 minutes99403 45 minutes99403 60 minutes

Note: These codes are included in the preventive medicine visit codes. Do not report CPT codes 99381-99397

Routine Bloodwork CodeVenipuncture: collection of venous blood • CPT 36415 – routine venipuncture (series 1)• Report 36415 for HIV blood screening for

bloodwork collected in physician’s office and sent to lab for processing (lab codes - series 2)

• Report applicable E&M counseling or service code as primary service

• 99201-99205: sick visit codes• 99381-99397: preventive visit codes• 99401-99403: counseling visit codes

HIV Test CodesHIV Antibody - tests for the presence of antibodies that are produced in response to the presence of the HIV infection

HCPCS/CPT CODE DESCRIPTION

86701 HIV 1; single result (RAPID)86702 HIV 2, single result (RAPID)86703 HIV 1 & HIV 2; single result (RAPID)86689 HIV confirmatory (Western Blot)G0435 HIV 1 and/or HIV 2; single result (RAPID)

Rapid Tests also known as “Point of Care” Tests

Rapid HIV Tests − Rapid tests provide “point of care”

screening and results− Alere DetermineTM HIV-1/2 Ag/Ab Combo

Test − OraSure Technology OraQuick

ADVANCE® Rapid HIV-1/2 Antibody Test− Trinity Biotech Uni-GoldTM Recombigen®

HIV-1/2− One test payable every 6 months

HIV Test CodesHIV Antigen – testing for the presence of the HIV infection

HCPCS/CPT CODE DESCRIPTION

G0432 EIA; HIV 1 and/or HIV 2 (RAPID)G0433 ELISA; HIV 1 and/or HIV 2 (RAPID)

87389EIA HIV 1 antibody with HIV 1 & HIV2 antigens; qualitative or semi-quantitative; single step (RAPID)

87390 EIA HIV 1; qualitative or semi-quantitative; multi-step

Rapid Tests also known as “Point of Care” Tests

HIV Test CodesHCPCS/CPT

CODE DESCRIPTION

87391 EIA HIV 2; qualitative or semi-quantitative; multi-step

87534 DNA/RNA; HIV 1; direct probe

87535 DNA/RNA; HIV 1; amplified probe

87536 DNA/RNA; HIV 1; quantification

87537 DNA/RNA; HIV 2; direct probe

87538 DNA/RNA; HIV 2; amplified probe

87539 DNA/RNA; HIV 2; quantification

Modifiers are two digit (numeric or alphanumeric)codes that indicate that a procedure or servicehas been altered by a specific circumstance, buthas not changed the code’s definition• There are CPT modifiers and HCPCS modifiers

• Some modifiers impact reimbursement

• Modifiers are never reported alone

• Modifiers are never reported on ICD-10-CM codes

− ICD-10-CM codes covered in Series 3

• Each state Medicaid agency determines the approved modifiers

― Contact your local Medicaid agency for specific guidance

Modifier 25 - Significant, Separately, Identifiable E&M Service by Same MD on the Same Day of a Procedure, Service or Other E&M Service• Only report with E&M service codes (99201-99499)

• Do NOT report with any other CPT code type

• Do NOT report with HCPCS lab codes

• Contact your local Medicaid agency for specific guidance

Modifier 92 - Alternative Laboratory Platform TestingWith current CDC recommendations on routine testing and the move toward HIV testing as a routine part of care, more providers may use rapid test kits. Several of these are CLIA waived and suitable for use in physician offices. The following is the CPT guidance for use of this modifier: “When laboratory testing is being performed using a kit or transportable instrument that wholly or in part consists of a single use, disposable analytical chamber, the service may be identified by adding modifier 92 to the usual laboratory procedure code (HIV testing 86701-86703).”• Only report with Path/Lab CPT test codes (86701-86703)• Do NOT report with any other code type• Do NOT report with HCPCS codes• Contact your local Medicaid agency for specific guidance

Modifier QW - CLIA waived testIn accordance with the Clinical Laboratory Improvement Amendments of 1988 (CLIA '88), a laboratory provider must have: a Certificate of Compliance, a Certificate of Accreditation or a Certificate of Registration in order to perform clinical diagnostic laboratory procedures of high or moderate complexity. Waived tests include test systems cleared by the FDA designated as simple, have a low risk for error and are approved for waiver under the CLIA criteria.

• Only report with Path/Lab test codes (86701-86703, 87389)• Do NOT report on any other code type• If a combination of waived and non-waived tests are

performed, modifier QW should not be used• Contact your local Medicaid agency for specific guidance

– According to the ICD-10-CM Official Coding Guidelines, ICD-10-CM code B20 includes the following terms:

– Acquired immune deficiency syndrome

– Acquired immunodeficiency syndrome

– AIDS– AIDS-like syndrome– AIDS-related complex

– HIV infection, symptomatic– HIV 1– Pre-AIDS– Prodromal AIDS– HIV Disease

• Asymptomatic HIV/HIV+ are not the same as AIDS/HIV infection– Never report them together

• Asymptomatic HIV/HIV+ and inconclusive HIV not the same– Never report together with confirmed

diagnosis of AIDS/HIV infection• When documentation states HIV-2:

– PDx=HIV-1– SDx=HIV-2

Inconclusive HIV Test• Newborn babies born to HIV+ moms have

mom’s diagnosis due to antibody status• HIV+ status in newborns lasts up to 18

months – Sometimes newborn never become infected– Known as a “False Positive”

– Inconclusive HIV test results another term for “False Positive”

– Assign inconclusive test code when documentation does not definitely state AIDS or HIV+

ICD-9-CMCodes Description ICD-10-CM

Codes Description

042

HIV Disease−AIDS−AIDS Like Syndrome−AIDS Related Complex (ARC)−Symptomatic HIV Infection−HIV 1

B20

HIV Disease−AIDS−AIDS Like Syndrome−AIDS Related Complex (ARC)−Symptomatic HIV Infection−HIV 1

V08

– Asymptomatic human immunodeficiency virus [HIV] infection status

– Asymptomatic HIV status−HIV+−HIV + status

Z21

– Asymptomatic human immunodeficiency virus [HIV] infection status

– Asymptomatic HIV status−HIV+−HIV + status

ICD-9-CM Codes Description ICD-10-CM

Codes Description

V65.44– Human immune

deficiency virus [HIV] counseling

– HIV Counseling

Z71.7– Human

immunodeficiency virus [HIV] counseling

– HIV Counseling

V73.89Special Screening for Other Specified Viral Diseases (HIV/AIDS)

Z11.4Encounter for screening for human immunodeficiency virus [HIV]

Z11.59 Encounter for screening for other viral diseases

ICD-9-CM Codes Description ICD-10-CM

Codes Description

795.71Nonspecific Evidence of HIV

−Inconclusive HIV Test (Adult) (Infant)

R75

Inconclusive laboratory evidence of human immunodeficiency virus [HIV] – Nonconclusive HIV test

findings in infants

Inconclusive HIV TestNewborn babies born to HIV+ moms have mom’s diagnosis due to antibody status– HIV+ status in newborns lasts up to 18 months

– Sometimes newborn never become infected– Known as a “False Positive”

– Inconclusive HIV test results=“False Positive”– Assign R75 when documentation does not definitely state AIDS or

HIV+

ICD-9-CM Codes Description ICD-10-CM

Codes Description

V01.79

Contact With/Exposure to Other Viral Diseases (HIV/AIDS)

−PrEPNOTE: Code also maps to Z20.5, Z20.828

Z20.6– Contact with and (suspected)

exposure to human immunodeficiency virus [HIV]

– PrEP

V69.2 High Risk Sexual Behavior

Z72.51 High risk heterosexual behavior

Z72.52 High risk homosexual behavior

Z72.53 High risk bisexual behavior

V69.8

Other Problems Related to Lifestyle−Asymptomatic high risk−Report as SDx code only (when applicable)NOTE: Code also maps to Z72.0, Z72.821, Z73.0-Z73.3)

Z72.89 Other problems related to lifestyle

ICD-9-CMCodes Description ICD-10-CM

Codes Description

079.52−Human T-cell lymphotrophic virus, type II [HTLV-II]

B97.34Human T-cell lymphotrophic virus, type II [HTLV-II] as the cause of diseases classified elsewhere

079.53HIV 2

−Report as SDxcode only (when applicable)

B97.35Human immunodeficiency virus, type 2 [HIV 2] as the cause of diseases classified elsewhere

V07.8Other specified prophylacticmeasure

Z41.8Encounter for other procedures for purposes other than remedying health state

V74.5Screening examination for venereal disease

Z11.3Encounter for screening for infectious with a predominantly sexual mode of transmission

ICD-9-CMCodes Description ICD-10-CM

Codes Description

V58.69Long-term (current) use of other medications

Z79.899

– Other long term (current) drug therapy

– Long term (current) drug therapy– Includes long term (current) drug

use for prophylactic purposes

V74.5Screening examination for venereal disease

Z11.3Encounter for screening for infectious with a predominantly sexual mode of transmission

Code Instructional Notes State: – Code also any therapeutic drug level monitoring (Z51.81)– EXCLUDES2

– Drug abuse and dependence (F11-F19)– Drug use complicating pregnancy, childbirth and the

puerperium (O99.32-)

Opportunistic Infections:ICD-9-CM

Codes Code Description ICD-10-CM Codes

112.0-112.9 Candidiasis (Thrush) B37.0-B37.9078.5 Cytomegalovirus (CMV) B25.0-B25.9

054.10-054.19 Herpes Simplex Virus (chronic)(HSV) A60.00-A60.9

176.0-176.9 Kaposi Sarcoma C46.0-C46.9084.0-084.9 Malaria B50.0-B50.9

NOTE: Check CDC’s website for comprehensive list of OI’s

ICD-9-CM Codes Code Description ICD-10-CM Codes

031.2 Mycobacterium AviumComplex (MAC or MAI) A31.2

136.3 Pneumocystis CariniiPneumonia (PCP) B59

130.0-130.9 Toxoplasmosis (Toxo) B58.00-B58.9011.00-018.96 Tuberculosis (TB) A15.0-A19.9

482.9 Recurrent severe bacterial pneumonia J15.9

799.4 • Cachexia• Wasting syndrome R64

NOTE: Check CDC’s website for comprehensive list of OI’s

Accidental Finger StickICD-9-CM

Code Description ICD-10-CMCodes Description

E920.5– Accident

caused by hypodermic needle

– Needlestick

W46.0xxA Contact with hypodermic needle, initial encounter

W46.0xxD Contact with hypodermic needle, subsequent encounter

W46.0xxS Contact with hypodermic needle, sequela

W46.1xxA Contact with contaminated hypodermic needle, initial encounter

W46.1xxDContact with contaminated hypodermic needle, subsequent encounter

W46.1xxS Contact with contaminated hypodermic needle, sequela

Never sequenced as the principal diagnosis code

*New Coding Changes*Some codes now require the following 7th

character values: – Disease of the musculoskeletal system

(pathological fractures)– Injury, Poisoning and Certain Other Consequences

of External Causes 7th Digit Description Coding Guidelines

A Initial encounter Patient receiving active treatment i.e. surgery, ED, Physician clinic/Office visit

D Subsequent encounter

Patient completes active treatment and presents for routine follow

S Sequela Patient follow up for sequale or residual effect

Well VisitsICD-9-CM

Codes Description ICD-10-CMCodes Description

V70.0– Routine

General Medical Exam

– Well Visit

Z00.00Encounter for general adult medical examination without abnormal findings

*Z00.01Encounter for general adult medical examination with abnormal findings

V20.2Routine infant or child health check

*Z00.121Encounter for routine child health examination with abnormal findings

Z00.129Encounter for routine child health examination without abnormal findings

NOTE: *Use additional code to identify any abnormal findings

ICD-9-CM Codes Description ICD-10-CM

Codes Description

V20.31

– Health supervision for newborn under 8 days old

– Health check for newborn under 8 days old

*Z00.110

– Health examination for newborn under 8 days old

– Health check for newborn under 8 days old

V20.32

– Health supervision for newborn 8 to 28 days old

– Health check for newborn 8 to 28 days old

– Newborn weight check

*Z00.111

– Health examination for newborn 8 to 28 days old

– Health check for newborn 8 to 28 days old

– Newborn weight check

NOTE: *Use additional code to identify any abnormal findings

ICD-9-CM Codes Description ICD-10-CM

Codes Description

V65.49Other specified counseling

Z70.0 Counseling related to sexual attitude

Z70.1 Counseling related to patient’ssexual behavior and orientation

Z70.3Counseling related to sexual behavior and orientation of third party (child, partner, spouse)

V67.9Unspecifiedfollow up exam

Z08Encounter for follow-up examination after completed treatment for malignant neoplasm

Z09Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm

Diagnoses Coding TipsNever report the code for AIDS (B20) or HIV+ (Z21) when the record states:

• Suspected• Suspicion of• Possible• Likely• Rule out

• Questionable• Consistent with• Presumed to be• Appears

Instead, report the codes for the:• Presenting complaint• Chief complaint• Signs or symptoms

• Example: muscle aches, rash, mouth/genital ulcers, swollen lymph glands (neck)

Diagnoses Coding TipsActive” versus “History of”

Active translates to “the current the condition”• B20 - AIDS/HIV Infection • Z21 - HIV+

– Codes for “History of” AIDS does not exist– Report AIDS (Dx code B20)

– Codes for “History of” HIV infection/ HIV+ does not exist

– Report AIDS (Dx code Z21)Provider documentation must clearly denote the medical condition to ensure proper coding in the outpatient settings

Maximizing Third Party ReimbursementThrough Enhanced

Medical Documentation and Coding

Coding Scenarios

HIV Counseling without Testing Case Study #1: A 17 year old patient presents to herGYN to discuss contraception options and safe sex. Dr.Attending counsels the patient on the various methodsand suggests an HIV test. The patient agrees, but thenminutes later declined to HIV screening test. Dr.Attending spends 30 minutes counseling the patientand asked her to reconsider the HIV test at a laterdate.

Report a preventive medicine counseling CPT code based on the total time spent

with the patient

Office Service 99402

Report the HIV Counseling

ICD-10-CMcode

Dx CodeZ71.7

HIV Counseling without Testing Case Study #1 Rationale:

• The patient presents for counseling on the various contraception options and safe sex.

• There is no distinction between new patient vs. established patient. Select the code based on the amount of time spent counseling the patient – CPT code 99402 – Do NOT report the preventive medicine visit E&M codes

• Patient presented for counseling only• All claims require a diagnosis code that supports the reason for the

patient encounter and to support procedures and services performed during the encounter.

• The patient presents for counseling on the various contraception options and safe sex (HIV counseling) – ICD-10 code Z71.7

NOTE : Check with your payors. Some health plans may not reimburse for counseling and may have alternate codes (i.e. 99201-99215) that they advise you to report.

Rapid HIV Testing with Preventive CareCase Study #2: A 27 year old patient presents to his primarycare physician’s office concerned about recently havingunprotected sex an requests an HIV test. Since this is a newpatient, Dr. Attending decides to perform a preventivemedicine visit exam and spends 15 minutes counseling thepatient and performs a rapid HIV test.

Report a preventive Report Dx Codes: Z00.00medicine CPT code based Well visit

’Office Service Z11.4on the patient s age and HIV screening

new patient status with the 99385-25 Z71.7HIV counselingapplicable modifier Z72.51High risk behavior

Report the rapid HIV test CPT Test Product Report Dx Codes: Z11.4HIV screening code with the applicable 86701-92 or Z71.7HIV counselingmodifier QW Z72.51High risk behaviorNote: This is a point of care test performed by PCP’s and can be reported for HIV testing for same day results.

Rapid HIV Testing with Preventive CareCase Study #2 Rationale:• This is a general medical exam (well visit) for a patient that presents with

no medical problems and HIV testing is performed

• Report the initial preventive medicine visit E&M code – CPT 99385

• Since the preventive medicine visit E&M codes include counseling as a component, do NOT report the counseling codes separately.

• The medical record states that this is a point of care test performed by PCP’s and can be reported for HIV testing for same day results – CPT 86701

• Both codes require the use of modifiers

− Append modifier 25 to the preventive medicine E&M code to − designate a separate, identifiable service is rendered− Append modifier 92 or QC to the HIV test code (check with your

local Medicaid agency for the applicable modifier)

Rapid HIV Testing with Preventive CareCase Study #2 Rationale (con’t):ICD-10 codes• This is a general medical exam (well visit) for a

patient that presents with no medical problems

• The codes should be sequenced as follows:– The physician performs a well adult exam – code Z00.00

– The physician performs an HIV (special) screening test – code Z11.4

– The physician counsels the patient (HIV counseling) – code Z71.7

– The patient indicates that they recently had unprotected sex –code Z72.51

Rapid HIV Testing with Preventive CareCase Study #3: A 27 year old patient presents to his PCP’s officeconcerned about recently having unprotected sex and requestsan HIV test. The physician notices that the patient is also due for awell visit this year and performs it. The PCP decides to perform apreventive medicine visit exam and spends 15 minutes counselingthe patient and performs a rapid HIV test. This is an establishedpatient.

Note: This is a point of care test performed by PCP’s and can be reported for HIV testing for same day results.

Report a preventive medicine code Report Dx Codes:Office Z00.00

based on the patient’s age and Well visit Z11.4established patient status with the Service HIV screening Z71.799395-25 HIV counselingapplicable modifier High risk behavior Z72.51

Report the rapid HIV test code with Test Report Dx Codes: Z11.4the applicable modifier Product HIV screening Z71.786701-92 or HIV counseling

QW High risk behavior Z72.51

Rapid HIV Testing with Preventive CareCase Study #3 Rationale:• This is a general medical exam (well visit) for a patient that presents with

no medical problems and HIV testing is performed

• Report the established preventive medicine visit E&M code – CPT 99395

• Since the preventive medicine visit E&M codes include counseling as a component, do NOT report the counseling codes separately.

• Medical record states that this is a point of care test performed by PCP with same day results rapid HIV test code – CPT 86701

• Both codes require the use of modifiers

− Append modifier 25 to the preventive medicine E&M code to designate a separate, identifiable service

− Append modifier 92 or QC to the HIV test code (check with your local Medicaid agency for the applicable modifier)

Rapid HIV Testing with Preventive CareCase Study #3 Rationale (con’t): ICD-10 codes• This is a general medical exam (well visit) for a patient that

presents with no medical problems

• The codes should be sequenced as follows:

– The physician performs a well adult exam

– No abnormal findings were noted during this encounter – code Z00.00

– The physician performs an HIV (special) screening test – code Z11.4

– The physician counsels the patient (HIV counseling) – code Z71.7

– The patient indicates that they recently had unprotected sex –code Z72.51

Case Study #4: A 47 year old male patient presents totheir PCP concerned about unprotected sex. PCPspends 35 minutes counseling the patient, draws bloodand sends the specimen to the lab for processing. Thisis an established patient visit.

Report a counselingcode based on the totaltime spent counseling 99402-25the patient

Dx#1 - Special Screening for other specified viral Z11.4diseases (HIV screening)

Dx#2 - HIV Counseling Z71.7Dx#3 - High Risk SexualBehavior Z72.51Report the venipuncture

code for blood work 36415NOTE 1: This is an HIV test performed by the PCP and sent downstairs to the onsite lab (or offsite) for processing.

NOTE 2: Check with your payors. Some health plans may not reimburse for counseling and may have alternate codes (i.e. 99201-99215) that they advise you to report.

Case Study #4 Rationale:• Counseling code selection is based on total time spent

counseling the patient • PCP performed HIV blood test. PCP’s can only bill for point of

care/rapid HIV screening tests.– Since there is an onsite lab, the specimen is sent to the

Pathologist to process.

• Append modifier 25 to the E&M counseling code − Check with your local Medicaid agency for the

applicable modifier)

NOTE 1: This is an HIV test performed by the PCP and sent downstairs to the onsite lab (or offsite) for processing.

NOTE 2: Check with your payors. Some health plans may not reimburse for counseling and may have alternate codes (i.e. 99201-99215) that they advise you to report.

HIV Testing with CounselingCase Study #4 Rationale:ICD-10 codes • The codes should be sequenced as follows:

− The physician performs an HIV (special) screening test – code Z11.4

− The physician counsels the patient (HIV counseling) – code Z71.7

− The patient indicates that they recently had unprotected sex – code Z72.51

Case Study #5: A 47 year old HIV+ patient presents totheir PCP for follow-up care. Patient has a history of IVdrug use. PCP spends 10 minutes counseling thepatient, documents an expanded problem focusedhistory and draws blood. Specimens are sentdownstairs to the on-site lab for processing. This is anestablished patient visit.

Report an establishedpatient office visit E&M Dx#1 – HIV+ Z21CPT code based on level 99213-25of history, exam and Dx#2 - HIV Counselingmedical decision making Z71.7

Dx#3 - Other Problems Report the venipuncture code 36415 Related to Lifestylefor blood work Z72.89(Asymptomatic high risk

Case Study #5 Rationale:• An expanded problem focused history and brief exam is

performed and documented in the health record. – Assign an established patient E&M code based on the level of

care provided

• PCP performed HIV blood test. PCP’s can only bill for point of care/rapid HIV screening tests.– Assign the CPT code for venipuncture– Since there is an onsite lab, the specimen is sent to the

Pathologist to process.

• Append modifier 25 to the E&M counseling code − Check with your local Medicaid agency for the applicable

modifierNote 1: This is an HIV test performed by the PCP and sent downstairs to the onsite lab (or offsite) for processing.

HIV Testing with CounselingCase Study #5 Rationale: ICD-10 codes• The codes should be sequenced as follows:

− Documentation states that the physician is HIV+ - code Z21

− The physician counsels the patient (HIV counseling) – code Z71.7

− Documentation states that patient has a history of IV drug use – code Z72.89

HIV Post-Test Counseling Negative Results

Case Study #6: The patient returns for HIV test results.The physician advises the patient that the results arenegative and counsels the patient for 30 minutes onthe importance of safe sex and contraceptivemethods. The physician also distributes contraceptionand HIV/AIDS education literature.

Report a preventive medicine counseling CPT HIV Counseling Z71.7CPT code based on the total time spent Code counseling the patient High Risk 99402 Z72.51Behavior

HIV Post-Test Counseling Negative Results

Case Study #6 Rationale:• The patient returned for their HIV test results. Since the results

are negative and counseling on safe sex was documented, report the preventive medicine counseling E&M code based

− Select the code based on the amount of time spent counseling the patient – CPT code 99402

• The patient returned for their HIV test results. The physician documents the results and counsels the patient on the importance of safe sex practices – ICD-10 codes Z71.7 and Z72.51

NOTE: Check with your payors. Some health plans may not reimburse for counseling and may have alternate codes (i.e. 99201-99215) that they advise you to report.

HIV Post-Test Counseling HIV Positive Results (Asymptomatic)

Case Study #7: The patient returns for their HIV test results.The physician advises the patient that they are HIV+(asymptomatic HIV). The physician counsels the patient for15 minutes on the importance of safe sex, dispensesprescription medication and distributes HIV/AIDS educationmaterials. A treatment plan is also prepared and discussedwith the patient. This is an expanded problem focusedhistory with low medical decision making established patientvisit.Report an establishedpatient office visit E&M Office HIV+ (HIV+ status/

asymptomatic HIV) Z21CPT code based on level of history, exam E&Mand medical decision 99213 HIV Counseling Z71.7making

Case Study #7 Rationale:• The patient returned for HIV test results. Since the results are

positive, this is considered a sick visit encounter.• An expanded problem focused history with low medical

decision making is performed and documented in the health record.

• Prescriptions are dispensed and documented in the health record.

• Instructions for proper medication use and treatment plan are both documented in the health record.

• The E&M components are: expanded problem focused history and low medical decision making.

– Assign an established patient E&M code based on the level of care provided.

− The E&M code for this scenario is 99213.

HIV Post-Test Counseling HIV Positive Results (Asymptomatic)

Case Study #7 Rationale (con’t): ICD-10 codes • The patient returned for their HIV test results. The

medical record states that the patient is HIV+ (asymptomatic) – code Z21

• The physician counsels the patient. The physician gives the patient some education materials and counsels on the importance of safe sex practices –code Z71.7

HIV Post-Test Counseling AIDS Results (Symptomatic)

Case Study #8: The patient returns for HIV test results.The physician advises the patient that the results arepositive for HIV infection (symptomatic HIV/AIDS). Thephysician counsels the patient for 15 minutes on theimportance of safe sex, distributes HIV/AIDS educationliterature and implements a treatment plan. This is anexpanded problem focused history with low medicaldecision making established patient visit.

AIDSReport an established patient Office (HIV infection) B20

office visit E&M CPT code based on level of history, exam and E&Mmedical decision making 99213 HIV Counseling Z71.7

Case Study #8 Rationale:• The patient returned for HIV test results. Since the results are

positive, this is considered a sick visit encounter.• A brief history and exam is performed and documented in the

health record.• Prescriptions are dispensed and documented in the health

record.• Instructions for proper medication use and treatment plan are

both documented in the health record.• The E&M components are: expanded problem focused history

and medical decision making is low.– Assign an established patient E&M code based on the level of

care provided.− The E&M code for this scenario is 99213.

HIV Post-Test Counseling AIDS Results (Symptomatic)

Case Study #8 Rationale (con’t):ICD-10 codes− The patient returned for their HIV test results. The

medical record states that the patient has AIDS (symptomatic HIV) – code B20

− The physician counsels the patient for 20 minutes and distributes HIV/AIDS education literature

− The physician implements a treatment plan, discusses the importance of taking medications and the importance of practicing safe sex at all times – code Z71.7

HIV Post-Test Counseling AIDS Results (Symptomatic)

Case Study #9: Patient returns for HIV test results. Thephysician advises the patient of a confirmed diagnosis ofthe HIV-2 infection. The physician counsels the patient for 15minutes on the importance of safe sex, distributes HIV/AIDSeducation literature and implements a treatment plan. This isan expanded problem focused history with low medicaldecision making established patient visit. (Note: This patientrecently relocated to the U.S. from West Africa; a countrywith a high prevalence of HIV-2 infection.)

Report an establishedpatient office visit E&M B20Office AIDS (HIV infection)

CPT code based on level of history, exam and E&M HIV-2 Infection B97.35medical decision making 99213 HIV Counseling Z71.7

Case Study #9 Rationale:• The patient returned for their HIV test results. Since the results

are positive, this is considered a sick visit encounter.• A brief history and exam is performed and documented in

the health record.• Prescriptions are dispensed and documented in the health

record.• Instructions for proper medication use and treatment plan

are both documented in the health record.• The E&M components are: expanded problem focused

history and medical decision making is low.− Assign an established patient E&M code based on the level of

care provided.– The E&M code for this scenario is 99213.

HIV Post-Test Counseling AIDS Results (Symptomatic)

Case Study #9 Rationale (con’t):ICD-10 codes• The patient returned for their HIV test results. The medical record

states that the patient has HIV-2 infection – ICD-10-CM codes B20 + B97.35

• Assign ICD-10-CM code B20 for HIV–1. This code is always sequenced as the principal diagnosis code (PDx).

• Assign ICD-10-CM code B97.35 for HIV-2. This code is always sequenced as the secondary diagnosis code (SDx). This code is never reported alone.

• The physician counsels the patient and explains HIV-2 infection in detail. The physician implements a treatment plan, discusses the importance of taking medications and the importance of practicing safe sex at all times – ICD-10 code Z71.7.

Case Study #10: An HIV+ mom presents to thepediatrician’s office for antiretroviral therapy follow-up forher 2 month old baby. The physician documents anexpanded problem focused history and performs a briefexam. Upon review of the lab results, the physician makesthe decision to modify the antiretroviral medication. Arevised treatment plan is discussed and the physicianadvises the patient to return in 1 month. Medical decisionmaking is low.Report an established Inconclusive HIV Testpatient office visit E&M R75OfficeCPT code based on E&M Contact with/exposurelevel of history, exam

99213 to other viral diseasesand medical decision Z20.6making (HIV/AIDS)

Case Study #10 Rationale:• An HIV+ mom presents to the pediatrician’s office with her 2

month old baby for antiretroviral therapy follow up.

• This is considered a sick visit encounter.

• An expanded problem focused history and brief exam is performed and documented in the health record.

• Lab results are reviewed which results in modification of the medication. Prescriptions are dispensed and documented in the health record.

• The E&M components are: expanded problem focused history, expanded problem focused exam and medical decision making is low.− Assign an established patient E&M code based on the level of

care provided: 99213

Case Study #10 Rationale (con’t):ICD-10 codes • An HIV+ mom visits the pediatrician’s office with her 2 month

old baby for antiretroviral therapy follow up.

• The newborn’s diagnosis of HIV+ is the is the result of the mother’s antibody status.

• “False positive” diagnoses could last up to 18 months in newborns.

• Report inconclusive HIV test results as the principal diagnosis code - ICD-10-CM R75.

• Report exposure to HIV/AIDS as the secondary diagnosis code - ICD-10 code Z20.6.

Case study #11: Patient with a history of AIDS comesto his primary care doctor for complaints of feverand extreme fatigue due to possible pneumonia.The physician documents an expanded problemfocused history, examines the respiratory system andissues a prescription for antibiotics. The finaldiagnoses are Pneumocystis carini pneumonia (PCP)and AIDS. (Established patient)

Report an establishedpatient office visit E&M Office AIDS B20CPT code based on level of history, exam E&Mand medical decision 99213 PCP B59making

Case Study #11 Rationale – Patient with a history of AIDS presents with

complaints of fever and extreme fatigue– This is considered a sick visit encounter.– An expanded problem focused history and low

medical decision making is documented in the health record.– Prescriptions are dispensed and documented in

the health record.– Assign an established patient E&M code based

on the level of care provided: 99213

Case Study #11 Rationale ICD-10 codes– Patient with AIDS presents with complaints of fever

and extreme fatigue – Final diagnoses documented in the medical record

are Pneumocystis carinii pneumonia (PCP) due to AIDS – Minimum of 2 diagnoses codes necessary to

accurately code this scenario– Coding guidelines state when AIDS related

conditions (OI) are present sequence AIDS as PDx PDx - AIDS: B20 SDx – PCP (AIDS related OI): B59

Case study #12: Patient with a history of AIDS and post op TAHpresents with complaints of nausea, vomiting and dehydrateddue to chemo treatment earlier today. The patient also neededa refill of AIDS meds. The physician documents a detailed historywith moderate medical decision making. The final diagnoses arenausea, vomiting, dehydration due to chemo, invasive endo-cervical cancer and AIDS.

Nausea with vomiting due to chemo R11.2

Report an established patient Office

Dehydration due to chemo E86.0office visit E&M CPT code based on E&M Invasive endo-cervical

cancer C53.0level of history, 99214exam and medical Adverse effects of T45.1x5Adecision making antineoplastic drugs

AIDS B20

Case Study #12 Rationale – Patient with a history of AIDS and post op TAH

presents with complaints of nausea, vomiting and dehydrated due to chemo treatment earlier today.

– This is considered a sick visit encounter.– The physician documents a detailed history and

moderate medical decision making in the health record.– Prescriptions are dispensed and documented in

the health record.– Assign an established patient E&M code based

on the level of care provided: 99214

Case Study #12 Rationale ICD-10 codes– Patient with h/o AIDS presents with complaints of

nausea, vomiting and dehydration due to chemo treatment

– Reason for medical care is not related to AIDS so this diagnosis should not be sequenced as the primary diagnosis PDx: nausea with vomiting due to chemo treatment

=R11.2 SDx: dehydration due to chemo treatment=E86.0 3rd: cervical cancer=C53.0 4th: adverse effects of chemo treatment =T45.1x5A 5th: AIDS condition=B20

Case study #13: A 5 month (20 weeks) pregnant patientwith a history of AIDS presents to her OB appointmentcomplaining of severe cramping and heavy bleeding.The physician documents a comprehensive history. Highmedical decision making includes the patient being puton IV meds and the bleeding stopped. The patient wassent to the hospital Labor and Delivery dept.

Report an Threatened abortion in early pregnancy O20.0

established patient office visit E&M CPT Infectious and code based on 99215 parasitic conditions O98.712level of history, complicating

pregnancy exam and medical decision making AIDS B20

Case Study #13 Rationale – A 5 month (20 weeks) pregnant patient with a

history of AIDS presents to her OB appointment complaining of severe cramping and heavy bleeding.

– This is considered a sick visit encounter.– The physician documents a comprehensive

history and high medical decision making includes IV meds.– Patient was sent to labor and delivery.– Assign an established patient E&M code

based on the level of care provided: 99215

Case Study#13 Rationale ICD-10 codes– Pregnant patient with a history of AIDS presents to her

OB appointment complaining of severe cramping and heavy bleeding.

– Code sequencing guidelines for pregnant patients state that the pregnancy codes are always sequenced as the principal diagnosis even when the patient is diagnosed with AIDS PDx=pregnancy complication code (O20.0) Sdx=infectious and parasitic conditions in

pregnancy (O98.71) 3rd code=AIDS code (B20)

NOTE: If a pregnant patient with asymptomatic HIV infection status is admitted during pregnancy, childbirth or the puerperium, assign codes O98.71and code Z21 for asymptomatic HIV infection

Case study #14: A medical assistant accidentally punctures fingerwith needle after drawing bloods from an AIDS patient. The officemanager completes the workplace injury forms while the medicalassistant is treated by physician in your office. The physicianperforms a detailed history and problem focused exam. Medicaldecision making includes blood work, a supply 48 hour PEPmedication and counsels the medical assistant regardingtransmission prevention. Bloodwork sent to lab for processing.

Report an established Special Screening for Other patient office visit E&M CPT Specified Viral Diseases Z11.4code based on level of 99203-25 (HIV/AIDS)

history, exam and medical Pre-exposuredecision making prophylaxis Z20.6

HIV counseling Z71.7Routine venipuncture 36415 Contact with contaminated

hypodermic needle, initial encounter W46.1xxA(ICD-9 says accident)

Case Study #14 Rationale:– This is an encounter for an accidental needle stick after

drawing bloodwork from an AIDS patient– This is considered a sick visit encounter.

– The physician documents a detailed history, problem focused exam and medical decision making includes blood work, a supply 48 hour PEP medication and counsels the medical assistant regarding transmission prevention

– Assign an established patient E&M code based on the level of care provided: 99213

– Append modifier 25 to the E&M service to indicate that a separate service was also rendered

– Check with your local Medicaid agency for the applicable modifier

Case Study 14 Rationale:ICD-10 codes– This is an encounter for an accidental needle

stick after drawing bloodwork from an AIDS patient

– The codes should be sequenced as follows: PDx=HIV (special) screening test code (Z11.4) SDx=Contact with or (suspected) exposure to HIV

(Z20.6) 3rd =HIV counseling code (Z71.7) 4th=contact with contaminated hypodermic needle

(W46.1xxA) – This is an external cause code that further describes

the accidental finger stick

Maximizing Third Party ReimbursementThrough Enhanced

Medical Documentation and Coding

Closing Comments

• HIV Testing with Preventive Care including Counseling

Report:−CPT 99381-99387 for patients that meet the new

patient criteria−CPT 99391-99397 for patients that meet the

established patient criteria• HIV Counseling without Testing (excluding

Preventive Care)Report:−CPT 99401-99404 based on the time spent

counseling the patient

• HIV Post Test Counseling (Results Negative)Report:─ CPT 99401 to 99404 - OR - CPT 99211 to 99215

• HIV Post Test Counseling with Coordination of Care (Results Positive)Report:– CPT 99401 to 99404 - OR - CPT 99211 to 99215

NOTES– E&M counseling or established patient codes– Contact your local Medicaid agency for specific coding guidance

• HIV Pre-Test with Testing and Preventive Care including Counseling

Report:− The applicable CPT/HCPCS code for the HIV test

performed − The applicable HIV test modifier

• HIV Counseling without Testing (excluding Preventive Care)

Report:− The applicable CPT/HCPCS code for the HIV test

performed − The applicable HIV test modifier

• Point of Care (Rapid HIV) Testing and Preventive Care including CounselingReport:- The applicable CPT/HCPCS code for the HIV test performed - The applicable HIV test modifier

• Point of Care (Rapid HIV) Testing including Counseling (without Preventive Care)Report:- The applicable CPT/HCPCS code for the HIV test performed - The applicable HIV test modifier

• HIV Testing/Confirmatory Testing processed by PathologistReport:- Codes G0432-G0433, 87389-87391, 87534-

87539 for non-rapid testing- CPT 86689 for confirmatory testing - The applicable HIV test modifier

• Physicians’ income historically driven by procedural coding and documentation; not diagnoses– Physician undercoding and overcoding a

major threat to revenue– Reimbursement adversely affected, if

physicians do not document the full range of diagnoses and complications treated

– Significant co-morbidities and severity greatly influence reimbursement• Diagnosis of AIDS/HIV+ map to chronic

condition risk pools

– All patients are assigned a severity level (risk score) based on chronic health conditions

– Projects health care utilization and costs– Patient demographics,

procedures/services, pharmacy claims and medical claims contain diagnoses

Diagnoses Coding Tips• Assign all diagnoses code that

accurately describes the medical problem being treated or the reason for health care encounter (Dx code ranges: A00.0-T88.9xxA; AIDS/HIV: B20, Z21)– Significant chronic conditions documented in

medical record should be coded accordingly

– Greatly impacts risk based reimbursement and quality incentives (QARR/HEDIS, PQRS)

– Codes reported on health care claims should match information documented in the health record

Diagnoses Coding TipsCode Sequencing • When it is necessary to report multiple

diagnoses codes, accurate interpretation of coding guidelines ensures proper code sequencing

– Ensure proper sequencing of all diagnoses codes; especially for procedures & diagnostic tests

– Coding guidelines that denote “principle diagnosis” vs. “secondary diagnosis” only, must be adhered to

Diagnoses Coding Tips− Codes designated as principal diagnosis codes are always sequenced first− Codes designated as secondary/subsequent diagnoses codes are never sequenced first− OI codes are always assigned as the secondary diagnoses if supported by medical record documentation

•ICD-10-CM code B20 always the principal diagnosis

•OI condition code always the secondary diagnosis

Diagnoses Coding TipsNever report the code for AIDS (B20) or HIV+ (Z21) when the record states:

• Suspected• Suspicion of• Possible• Likely• Rule out

• Questionable• Consistent with• Presumed to be• Appears

Instead, report the codes for the:• Presenting complaint• Chief complaint• Signs or symptoms

• Example: muscle aches, rash, mouth/genital ulcers, swollen lymph glands (neck), fever

Query physician for clarification

Diagnoses Coding TipsActive” versus “History of”

Active translates to “the current the condition”• B20 - AIDS/HIV Infection • Z21 - HIV+

– Codes for “History of” AIDS does not exist– Report AIDS (Dx code B20)

– Codes for “History of” HIV infection/ HIV+ does not exist

– Report AIDS (Dx code Z21)

Provider documentation must clearly denote the medical condition to ensure proper coding in the outpatient settings

Still Using Paper Charts?• Use standard medical abbreviations,

acronyms, or symbols• Do not use arrows up/down (↑↓) in place

of “hyper-“ and “hypo-“, as they could be misinterpreted

• Medical conditions under physician care must clear and concise to ensure proper translation to numeric diagnoses codes

Documentation Tips

Documentation Tips• Each visit date documented in the

medical record must be able to “stand alone” – Chronic conditions documented in

one note, must be re-documented in every subsequent note when treatment is directed to the condition

– Documentation which states, see previous visit, prior note, problem list, etc., are deemed unacceptable

Documentation Tips• Problem lists with no evaluation or

assessment of medical conditions in chart deemed unacceptable for encounter data submission – CMS mandates that an evaluation of each medical

condition be documented in the medical record; not just the condition listed as “a problem”

– HIV+ - stable on meds– DM w/Neuropathy - meds adjusted– CHF – compensated– COPD – test ordered– HTN – uncontrolled– Hyperlipidemia - stable on meds

• Medical record documentation must support the services submitted on claims to the local Medicaid agency– Codes reported on health care claims

should match• Documentation should substantiate:

− Medical necessity (diagnoses being treated)

− Final diagnosis code selection

• Documentation inaccuracies result in payment recovery and heavy sanctions by the Office of Medicaid Inspector General (OMIG)− Sanctions and penalties include:

• Restricted/Excluded from provider participation

• Termination from provider participation• Huge fines• Jail time

• Centers for Medicare and Medicaid Services (CMS)http://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/index.htmlhttp://www.cms.gov/center/coverage.asp

• Food and Drug Administration (FDA) http://www.fda.gov/MedicalDevices/DeviceRegulationandGuidance/IVDRegulatoryAssistance/ucm124105.htm

• American Medical Association (AMA) http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/cpt.page

• National Center for Health Statistics (NCHS)http://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/index.html

• Centers for Disease Control (CDC)http://www.cdc.gov/hiv/

Web Resources

• American Academy of Professional Coders (AAPC)http://www.aapc.com/resources/index.aspx

• American Health Information Management Association (AHIMA) http://www.ahima.org/resources/default.aspx

• The American Academy of Family Physicians (AAFP) -www.aafp.org/online/en/home/practicemgt/codingresources.html

• American Hospital Association (AHA) –http://www.aha.org/advocacy-issues/medicare/ipps/coding.shtml

Web Resources

• CPT® 2015 Professional Edition. Publisher: American Medical Association.

• HCPCS Level II 2015. Publisher: Ingenix Optum.

• ICD-10-CM, Volumes 1 & 2, Professional. Publisher: Ingenix Optum.

• Faye Brown’s ICD-10-CM Coding Handbook 2015 (with Answers). Publisher: American Hospital Association.

• ICD-10-CM Fast Finder Sheets. Publisher: Ingenix Optum.Note: Coding resources are updated annually. Please be sure to update coding resources each year.

Other Resources

QUESTIONS?

HealthHIV2000 S ST NW

Washington, DC 20009202.507.4730

www.HealthHIV.org

Brian HujdichBrian@HealthHIV.org

Michael D. Shankle, MPHMichael@HealthHIV.org

Thank you for participating in this Webinar. We hope that you are able to find the information provided

useful as you continue your P4C project. We ask that you take a few moments to complete the feedback survey you will receive when you close out of this

webinar.

Thank you for participating in today’s webinar

Please email if you have any question(s): P4CHIVTAC@mayatech.com